Excisional biopsy with margin control for oral cancers

Comparison of survival between palliative surgery and no surgery for advanced tongue squamous cell carcinoma: an analysis of SEER data

The aim of this study was to investigate the survival effect of palliative surgery in advanced tongue squamous cell carcinoma (TSCC). A retrospective analysis of data in the SEER database for 6151 patients with stage III/IV TSCC (American Joint Committee on Cancer (AJCC) staging), diagnosed between 2004 and 2015, was performed. The patients were divided into two groups: palliative surgery and no surgery. Kaplan-Meier and Cox proportional hazards regression analyses were applied to determine risk factors for overall survival (OS) and cancer-specific survival (CSS). A further analysis was performed using 1:1 propensity score matching (PSM) to balance 13 patient variables (sex, age at diagnosis, race, marital status, primary tumour site, SEER stage, AJCC stage, pathological differentiation grade, tumour size, lymph node metastasis, previous lymph node removal, radiotherapy, and chemotherapy). Among the 6151 patients, 706 underwent palliative surgery; the other 5445 did not undergo any kind of surgery. Those who underwent palliative surgery had a higher 5-year survival rate. After PSM, 1274 patients were included in the matched cohort. Multivariate Cox regression analysis showed that patients who underwent palliative surgery had a lower risk of death than those who did not (OS: hazard ratio 0.58, 95% confidence interval 0.49-0.69, P < 0.001; CSS: hazard ratio 0.60, 95% confidence interval 0.49-0.74, P < 0.001). In this comparative study it was found that compared with no surgery, palliative surgery has a positive impact on the survival rate of patients with advanced TSCC.

Symphyseal-Sparing Mandibulectomy for Canine Acanthomatous Ameloblastoma in Dogs: 35 Cases

Canine acanthomatous ameloblastoma (CAA) has been reported to be the most prevalent odontogenic tumor in dogs. The most common location of this tumor is the rostral mandible. Symphyseal-sparing mandibulectomy has been shown to be an effective technique to maintain mandibular continuity and promote early return to function. In this retrospective study, 35 dogs with CAA associated with a mandibular canine tooth were evaluated following a symphyseal-sparing rostral mandibulectomy. Dogs with intraoperative transection of the canine tooth root and subsequent root fragment extraction were included. The objective of this study was to evaluate outcome following excision of CAA with mid-root transection. Data retrospectively evaluated in this study included the following: narrowest tumor margin, narrowest tumor margin at the border associated with the transected canine root, tumor size, and prevalence of local recurrence. This study showed that 82.86% of CAA were completely excised with tumor-free margins (N = 29). The median narrowest overall tumor-free margin was 3.5 mm (interquartile range [IQR] 2.0-6.5 mm) and the median tumor-free margin associated with the border of the transected canine root was 5.0 mm (IQR 3.1-7.0 mm). Follow-up data was obtained in 25 cases via phone interviews with referring veterinarians and clients. No local tumor recurrence was reported in cases with incomplete tumor excision (N = 5). All dogs with follow-up data survived at least 1 year following surgery. It was concluded that segmental or rostral mandibulectomy with wide margins to include the entire mandibular canine tooth with subsequent mandibular instability may not be warranted for dogs with CAA associated with this tooth.

A new scoring system facilitating diagnosis of oral squamous malignancy on biopsy specimens

BACKGROUND

Morphological evaluation of oral mucosal biopsy is sometimes inconclusive, which may delay the diagnosis and treatment of oral squamous malignancy. Immunohistochemical biomarkers denoting oral squamous malignancy would be clinically helpful in such scenario.

METHODS

We first studied the expression patterns of four potential biomarkers (cytokeratin 13, cytokeratin 17, Ki-67 and laminin 5 gamma 2 chain) in an exploratory cohort containing 54 surgical specimens from confirmed oral squamous malignancies. A pattern score was assigned to each specific expression pattern of these four biomarkers. A total score from each specimen was then calculated by summing up the four pattern scores. A cut-off value of total score denoting oral squamous malignancy was then determined. Another 34 oral squamous malignancies that were misdiagnosed as non-malignant lesions on their pre-treatment biopsies were used as a validation cohort to test the clinical utility of this scoring system.

RESULTS

In the exploratory cohort, fifty-two (96%) of the 54 confirmed oral squamous malignancies had a total score of 9 and above. In the validation cohort, thirty-one (91%) of the 34 pre-treatment oral biopsy specimens also had a total score of 9 or above, supporting the feasibility of using this scoring system to predict immediate risk of oral squamous malignancy.

CONCLUSIONS

Our four-biomarker "oral squamous malignancy scoring system" provides reliable prediction for immediate risk of oral squamous malignancy on pre-treatment oral biopsies.

Clinical value of entire-circumferential intraoperative frozen section analysis for the complete resection of superficial squamous cell carcinoma of the tongue

OBJECTIVES

We aimed to evaluate the clinical value of an entire-circumferential intraoperative frozen section analysis (e-IFSA) for the complete resection of superficial squamous cell carcinoma (SCC) of the tongue.

MATERIALS AND METHODS

A total 276 specimens from 51 patients with pT1-2, N0, mucosal or submucosal invasion SCC were analyzed to evaluate the diagnostic accuracy of the e-IFSA and the added value of the e-IFSA to iodine staining. The e-IFSA results were compared with the final histologic results obtained using permanent sections. All specimens for the e-IFSA were taken over the entire circumference 5 mm outside from the iodine unstained areas. The outline of the main resected specimen after taking these outer mucosal specimens were defined as the surgical margins determined by iodine staining alone.

RESULTS

The e-IFSA results were in excellent agreement with final histological results (Cohen's kappa value: 0.85) and the e-IFSA showed high sensitivity (100%) and high negative predictive value (100%). The actual complete resection rate with an e-IFSA was 100% (51/51), and no patient required additional resection after surgery. In contrast, 10/51 patients (20%) patients showed residual atypical mucosal epithelium at or beyond the margin determined by iodine staining alone; this difference was statistically significant (P = 0.002). The 5-year local control rate and 5-year overall survival rate after this procedure were both 100%.

CONCLUSION

An e-IFSA has additional value when performed in conjunction with iodine staining. An e-IFSA would be useful for achieving complete resection of superficial SCC of the tongue.

Oral epithelial dysplasia: Causes, quantification, prognosis, and management challenges

Oral epithelial dysplasia is a spectrum of architectural and cytological epithelial changes caused by accumulation of genetic changes, and is associated with an increased risk of progression to squamous cell carcinoma. It is a microscopic diagnosis of immense clinical importance. The initial reports of oral potentially malignant disorders with oral epithelial dysplasia transforming to oral cancer helped in understanding the nature of oral malignancies. Since then, clinical studies on oral potentially malignant disorders have combined microscopic findings of oral epithelial dysplasia to assess the malignant transformation potential of different grades of epithelial dysplasia. A significant amount of scientific literature has amassed on oral epithelial dysplasia relating to aspects of its diagnosis and management. However, the evidence base is weak as a result of the significant variability of published research. Poorly described study methods, variability in different oral epithelial dysplasia grading systems, inter- and intra-examiner variability causing issues of reliability, inadequate sample size, and inconsistent durations of follow-up are some of the methodological issues contributing to the failure to provide dependable information. Randomized clinical trials on the malignant transformation potential of oral epithelial dysplasia and its treatment outcomes are limited. This comprehensive literature review on oral epithelial dysplasia summarizes the scientific knowledge published in the scientific literature in English since its first description. The historical development, etiological factors, grading systems, diagnostic criteria, assessment of risk factors and prevention of malignant transformation, management principles of different grades of oral epithelial dysplasia (surgical and nonsurgical), recommendations on follow-up, and prognostic indicators are discussed in detail.

Molecular Analysis as a Guide to Determining the Extent and Pathophysiology of Perilesional Tissues in Oral Epithelial Dysplasias

Introduction

Clinically and histologically normal appearing perilesional mucosa of epithelial dysplasia may harbor early genetic changes. Hence, the present study is designed to determine the early molecular changes in the form of p16 and EGFR immunoexpressions in perilesional tissues.

Objectives

To analyze immunohistochemical expressions of p16 and EGFR individually and percentage change of immunoexpressions in oral dysplastic lesions and their perilesional tissues.

Materials and Methods

Forty formalin-fixed paraffin-embedded tissues of oral epithelial dysplasia with perilesional tissue marked by India ink were included in this study. Immunohistochemical staining was performed using anti-p16 and anti-EGFR monoclonal antibodies (BioGenex) using squamous cell carcinoma of uterine cervix and breast carcinoma as the positive controls, respectively.

Results

p16 and EGFR expressions were assessed based on the presence, intensity, extent and immunolocalization of positive cells. Out of 40 cases, p16 immunoexpression was positive in 82.5% cases of lesional tissues and in 62.5% cases of perilesional tissues (p ≤ 0.05); however, EGFR immunoexpression was positive in 90% cases of both lesional and perilesional tissues (p > 0.05).

Conclusion

The disease status and progression based on p16 and EGFR expressions and co-expressions can be used as an effective guide to evaluating the progression of normal epithelium to dysplastic epithelium in otherwise clinically normal mucosa.

Intraoperative frozen section histological analysis of resection samples is useful for the control of primary lesions in patients with oral squamous cell carcinoma

To ensure reliable surgical margins, intraoperative frozen section histological analysis (FS) has been performed since October, 2005 as follows: i) the orientation at the anatomical position and extent of the tumor are shared between oral pathologists and oral surgeons using imaging evaluations and pathological pictures and the planned site of sampling for intraoperative FS is confirmed; ii) a tumor team is organized and the team marks the tumor area and sets the resection range to correct the setting errors of the resection range among operators; iii) vital Lugol staining is applied to the lesion prior to tumor resection, the surgical margin is set based on the non-stained region and the extent of the tumor is macroscopically confirmed in the maximum cross-sectional surface of the resected specimen; and iv) FS is performed using samples from resected specimens to confirm the mucoepithelium and safety margin of the deep stump. The aim of this study was to evaluate the usefulness of our FS method. The treatment outcomes of oral squamous cell carcinoma were retrospectively investigated in patients treated prior to (Group 1) and after (Group 2) the introduction of our FS method. The recurrence rate of the primary lesions was high (17.3%) in Group 1, but decreased significantly in Group 2 (6.9%). Regarding clinicopathological factors, the condition of the surgical margins was associated with recurrence of the primary lesion in Group 1, but not in Group 2. In conclusion, our FS method appears to be useful for resecting tumors with reliable safety margins.

Excisional biopsy for management of lateral tongue leukoplakia

BACKGROUND

Leukoplakia of the lateral tongue is frequently associated with the risk of malignancy. Although incisional biopsy is accepted as a standard technique for evaluation, the possibility of underdiagnosis, and therefore missed diagnosis of malignancy, remains at all times. The aim of this study was to determine the rate of underdiagnosis by incisional biopsy for leukoplakia of the lateral tongue and to elucidate the underlying cause of for underdiagnosis.

METHODS

Twenty-two patients with leukoplakia in the lateral tongue who had undergone excisional biopsy for suspicion of malignancy were included in the study. Pathology was reviewed and classified into 'no dysplasia,''dysplasia,' and 'carcinoma'. Underdiagnosis was defined as a change of diagnosis to a graver classification following excisional biopsy. To analyze the factors contributing to underdiagnosis, incisional and excisional biopsy specimens were re-evaluated.

RESULTS

Of the 22 patients with leukoplakia of the lateral tongue, 59.1% had coexistent malignancy, including nine squamous cell carcinomas and four verrucous carcinomas. Incisional biopsy resulted in underdiagnosis in 73.3% of the cases. Underdiagnosis was attributable to three common errors, which were mis-selection of sampling site within a large area of leukoplakia, error in pathology specimen preparation owing to small specimen size, and superficial biopsy frequently associated with punch biopsy.

CONCLUSION

Leukoplakia of the lateral tongue is highly coexistent with malignancy, and incisional biopsy frequently leads to underdiagnosis. Therefore, complete excision with adequate margin is warranted for leukoplakia of the lateral tongue, preferably under general anesthesia, which could be performed with minimal morbidity and function preservation.